renal inflammatory disease

Renal Renal Infectious/InflamInfectious/Inflammatory Diseasematory Disease

Jud Gash, MDJud Gash, MD

OutlineOutline

PyelonephritisPyelonephritis Renal AbscessRenal Abscess Emphasematous PyelonephritisEmphasematous Pyelonephritis PyonephrosisPyonephrosis Xanthogranulomatous PyelonephritisXanthogranulomatous Pyelonephritis TBTB Renal MalakoplakiaRenal Malakoplakia Other InfectionOther Infection

PyelonephritisPyelonephritis PredispositionPredisposition

Most cases similar to lower UTI causes (esp Most cases similar to lower UTI causes (esp intercourse)intercourse)

About 20-30:1 cystitis to PNAbout 20-30:1 cystitis to PN Female, reflux, obstruction, stones, diabetes, Female, reflux, obstruction, stones, diabetes,

stasis (congenital anomalies, diverticula), stasis (congenital anomalies, diverticula), pregnancypregnancy

ClinicalClinical Gram negatives (E coli, Proteus, Pseudomonas, etc.)Gram negatives (E coli, Proteus, Pseudomonas, etc.) Flank pain and tenderness, fever, N/V, signs of Flank pain and tenderness, fever, N/V, signs of

cystitiscystitis

PyelonephritisPyelonephritis ImagingImaging

Usually not necessary (uncomplicated PN)Usually not necessary (uncomplicated PN) Reasons to image Reasons to image

Uncertain diagnosisUncertain diagnosis Severe symptomsSevere symptoms Atypical clinical situationAtypical clinical situation

men, unresolving, children, diabeticsmen, unresolving, children, diabetics Role out obstructionRole out obstruction Evaluate source in recurrent pyelonephritisEvaluate source in recurrent pyelonephritis

May see incidentallyMay see incidentally Note: imaging of PN/UTI in children whole Note: imaging of PN/UTI in children whole

separate topicseparate topic

PyelonephritisPyelonephritis PathophysiologyPathophysiology

Ascending Infection Ascending Infection Adhesions and Adhesions and

Endotoxins Endotoxins UreteropyelitisUreteropyelitis

Thickened, Thickened, enhancing enhancing UrotheliumUrothelium

Ureteral Ureteral ““ileusileus”” PyelonephritisPyelonephritis

Access/spread via Access/spread via papillapapilla

Wedge shaped and Wedge shaped and patchypatchy

Rarely Rarely hematogeneoushematogeneous

StaphStaph BilateralBilateral

UltrasoundUltrasound

RoleRole Detect ComplicationsDetect Complications

Pyonephrosis; abscessPyonephrosis; abscess Predisposing factorsPredisposing factors ScarringScarring

ImagingImaging Normal (75%?)Normal (75%?) EnlargementEnlargement Loss of corticomedullary Loss of corticomedullary

junctionjunction Decreased EchogenecityDecreased Echogenecity

Focal or diffuseFocal or diffuse Hyperechoic Hyperechoic

(hemorrhage)(hemorrhage) FocalFocal

Hypoechoic area on Hypoechoic area on Power DopplerPower Doppler

Severe unilateral acute bacterial pyelonephritis

Craig W D et al. Radiographics 2008;28:255-276

PyelonephritisPyelonephritis

Radiographics. 2000;20:215-243 Craig W D et al. Radiographics 2008;28:255-276

PyelonephritisPyelonephritis CTCT

NoncontrastNoncontrast NormalNormal NephromegalyNephromegaly Perinephric strandingPerinephric stranding Loss of hyperdense pyramidsLoss of hyperdense pyramids Hyperdensities (hemorrhage)Hyperdensities (hemorrhage) Thickening of urotheliumThickening of urothelium Mild ureteral dilationMild ureteral dilation

ContrastContrast Wedges of hypoattenuation (edema, obstruction, and Wedges of hypoattenuation (edema, obstruction, and

vasospasm)vasospasm) Dense on delayedDense on delayed

Striations (focal, diffuse)Striations (focal, diffuse) May be abnormal for days or weeksMay be abnormal for days or weeks RoleRole

Diagnosis/alternative diagnosisDiagnosis/alternative diagnosis Acute complicationsAcute complications Underlying predispositions (CTU)Underlying predispositions (CTU)

ED – flank pain (no stone ED – flank pain (no stone seen)seen)

PyelonephritisPyelonephritis DDXDDX

PNPN Recent stone passageRecent stone passage Non-stone obstruction Non-stone obstruction

(clot, fungus ball, (clot, fungus ball, iodinovir)iodinovir)

Acute vascular lesion Acute vascular lesion (RA, RV occlusion)(RA, RV occlusion)

So, non-contrast So, non-contrast findings nonspecific. findings nonspecific.

Clinical exam/UA/hydro Clinical exam/UA/hydro should allow distinctionshould allow distinction

Consider contrast if Consider contrast if unclearunclear

RadioGraphics 2004;24:S11-S28

Kawashima A - Infect Dis Clin North Am - 01-JUN-2003

Acute bacterial pyelonephritis caused by hematologic seeding in a patient with Staphylococcus aureus

endocarditis

Pyelonephritis – DDX (3 Pyelonephritis – DDX (3 II ’’s)s)

Radiographics. 2000;20:215-243

Focal PyelonephritisFocal Pyelonephritis Replaces old terms Replaces old terms

(FLN, ABN, etc.)(FLN, ABN, etc.) May be pre-abscess May be pre-abscess

statestate Now focal or diffuse Now focal or diffuse

pyelonephritispyelonephritis ImagingImaging

Focal mass-like lesion Focal mass-like lesion can mimic tumorcan mimic tumor

Complications of Complications of PyelonephritisPyelonephritis

AcuteAcute AbscessAbscess

RenalRenal PerinephricPerinephric

Emphysematous PNEmphysematous PN PyonephrosisPyonephrosis

ChronicChronic Scarring/AtrophyScarring/Atrophy XGP/malakoplakiaXGP/malakoplakia Papillary NecrosisPapillary Necrosis

AbscessAbscess

EtiologyEtiology PN which proceeds to tissue necrosis PN which proceeds to tissue necrosis

and liquefactionand liquefaction More likely with obstruction, diabetes More likely with obstruction, diabetes

(75% of all abscesses), stone disease(75% of all abscesses), stone disease Normal kidneys or superinfect pre-Normal kidneys or superinfect pre-

existing lesions (cysts, diverticula, RCC)existing lesions (cysts, diverticula, RCC) Can spread to perinephric spaceCan spread to perinephric space

AbscessAbscess

ImagingImaging USUS

Rounded, thick wall Rounded, thick wall cystic mass with debriscystic mass with debris

CTCT Rounded cystic lesion Rounded cystic lesion

with enhancing wallwith enhancing wall Surrounding Surrounding

inflammatory changesinflammatory changes Microabscesses Microabscesses

Small, often multiple Small, often multiple areas in the setting of areas in the setting of PNPN

Perinephric AbscessPerinephric Abscess

Usually Usually secondary to secondary to pyonephrosispyonephrosis Less commonly Less commonly

in in unobstructed unobstructed PNPN

Emphysematous Emphysematous PyelonephritisPyelonephritis

Aggressive form of PN with necrosis, Aggressive form of PN with necrosis, vascular compromise and air productionvascular compromise and air production

Rare life threatening form urologic Rare life threatening form urologic emergencyemergency

90% diabetics 90% diabetics (poorly controlled)(poorly controlled) Obstruction common (must exclude)Obstruction common (must exclude) AdultsAdults

Rare, if ever, seen in pediatricsRare, if ever, seen in pediatrics Clinical presentationClinical presentation

Fever, flank pain, lethargy, renal failure, septic Fever, flank pain, lethargy, renal failure, septic shockshock

Usually gram negatives, esp. E. ColiUsually gram negatives, esp. E. Coli

KUBKUB Gas collectionsGas collections Renal EnlargementRenal Enlargement Stones Stones

USUS Hyperechoic dirty Hyperechoic dirty

shadowingshadowing DDX: DDX:

nephrocalcinosis nephrocalcinosis and and nephrolithiasisnephrolithiasis

CTCT Parenchymal air – Parenchymal air –

bubbles, linearbubbles, linear Severe inflammatory Severe inflammatory

changeschanges Look for obstructionLook for obstruction

TreatmentTreatment Nephrectomy – Nephrectomy –

traditional gold traditional gold standardstandard

If more limited, If more limited, milder form – milder form – percutaneous percutaneous drainage/relief drainage/relief of obstruction of obstruction and antibioticsand antibiotics

Emphysemtous pyelitisEmphysemtous pyelitis

Gas in collecting Gas in collecting systemsystem

Same Same epidemiology as epidemiology as EPNEPN

Better prognosis Better prognosis Relief of Relief of

obstruction/ABXobstruction/ABX

Emphysemtous pyelitisEmphysemtous pyelitis

Air In Collecting SystemAir In Collecting System Emphysematous Emphysematous

PyelitisPyelitis FistulaFistula IatrogenicIatrogenic

Radiology. 2001;218:647-650

PyonephrosisPyonephrosis

Obstructed, infected kidney Obstructed, infected kidney Cause of obstructionCause of obstruction

Stones (rarely other: Conj UPJ, tumor)Stones (rarely other: Conj UPJ, tumor) EmergencyEmergency

UrosepsisUrosepsis Renal destructionRenal destruction XGP (chronic)XGP (chronic)

TreatmentTreatment Drainage (perc neph/stent and Drainage (perc neph/stent and

antibiotics)antibiotics)

PyonephrosisPyonephrosis USUS

Large, hypoechoic kidneyLarge, hypoechoic kidney HydronephrosisHydronephrosis Echogenic debrisEchogenic debris Fluid – Fluid LevelFluid – Fluid Level

Pyonephrosis – 4 casesPyonephrosis – 4 cases

PyonephrosisPyonephrosis CTCT

Findings of infectionFindings of infection Findings of obstructionFindings of obstruction Hypedense/debris in Hypedense/debris in

collecting system collecting system >30 hu (Note: 50%<15hu)>30 hu (Note: 50%<15hu)

Thick pelvic pelvic wall (2-Thick pelvic pelvic wall (2-5mm)5mm)

75% (Note: 10% of 75% (Note: 10% of uninfected obstruction)uninfected obstruction)

Emphysematous pyelitis Emphysematous pyelitis in 10%in 10%

Aspirate UrineAspirate Urine

Chronic PyelonephritisChronic Pyelonephritis

Controversial Controversial PathophysiologPathophysiologyy

FindingsFindings Renal ScarringRenal Scarring Calyceal Calyceal

ClubbingClubbing At Renal PolesAt Renal Poles

DDXDDX Renal infarctsRenal infarcts

Xanthogranulomatous Xanthogranulomatous PyelonephritisPyelonephritis

(XGP)(XGP) Disorder immune response in Disorder immune response in

setting of chronic infection, setting of chronic infection, often with obstruction and often with obstruction and stones (ie pyonephrosis)stones (ie pyonephrosis)

PathophysiologyPathophysiology Stone leads to obstructionStone leads to obstruction Caliectasis (peripelvic fibrosis Caliectasis (peripelvic fibrosis

limits pelviectasis). limits pelviectasis). Infection leads to parenchymal Infection leads to parenchymal

destruction and replacement destruction and replacement with lipid laden macrophageswith lipid laden macrophages

TreatmentTreatment nephrectomynephrectomy

(XGP)(XGP) Key pointsKey points

Middle age women with longstanding Middle age women with longstanding infection/stonesinfection/stones DM in only 10%DM in only 10%

TriadTriad NonfunctionNonfunction Renal enlargement Renal enlargement

Caliectasis with less pelviectasis, parenchymal lossCaliectasis with less pelviectasis, parenchymal loss Stones (90%)Stones (90%)

Staghorn, explodedStaghorn, exploded

(XGP)(XGP) KUBKUB

““explodedexploded”” staghorn with staghorn with large renal large renal shadowshadow

USUS Caliectasis Caliectasis

(massive) with (massive) with debrisdebris

Stones Stones Kawashima A - Infect Dis Clin North Am - 01-JUN-2003

(XGP)(XGP) CTCT

““Bear ClawBear Claw”” Massive caliectasis Massive caliectasis

(without (without pelviectasis)pelviectasis)

Not fluid thoughNot fluid though Parenchyma Parenchyma

enhances (not enhances (not function)function)

StonesStones

Xanthogranulomatous pyelonephritis

(XGP)(XGP)

(XGP)(XGP) Other FindingsOther Findings

Extrarenal Extrarenal ExtensionExtension

NodesNodes FistulaFistula SegmentalSegmental

TuberculosisTuberculosis PathophysiologyPathophysiology

Renal cortical Renal cortical deposition occurs deposition occurs in primary infectionin primary infection

Reactivation (one Reactivation (one kidney) in medullakidney) in medulla

Descending processDescending process Destruction, Destruction,

fibrosis, fibrosis, calcification, calcification, obstructionobstruction

DxDx Culture (sterile Culture (sterile

pyuria)pyuria)

TuberculosisTuberculosis

KUBKUB Diffuse or Diffuse or

scattered renal scattered renal calcifications calcifications (25%)(25%)

Often small Often small renal shadowrenal shadow

““putty kidneyputty kidney””

TuberculosisTuberculosis CTU (IVP)CTU (IVP)

RenalRenal Moth eaten, fuzzy calyx with Moth eaten, fuzzy calyx with

papillary necrosispapillary necrosis Infundibular, pelvic fibrosis Infundibular, pelvic fibrosis

(purse string pelvis)(purse string pelvis) Calyceal/pelvic obstruction Calyceal/pelvic obstruction

(hydrocalyx, phantom calyx)(hydrocalyx, phantom calyx) Renal nonfunction Renal nonfunction

(autonephrectomy), scarring (autonephrectomy), scarring calcification (putty kidney)calcification (putty kidney)

Note: renal changes mimic Note: renal changes mimic TCCTCC

UreterUreter Ulcerations and irregularity; Ulcerations and irregularity;

sawtooth (early)sawtooth (early) Multiple strictures; corkscrew Multiple strictures; corkscrew

(later)(later) Short, strait, aperistaltic Short, strait, aperistaltic

(latest)(latest) Calcifications (DDX: Calcifications (DDX:

schistosomiasis)schistosomiasis) Bladder involvement is very Bladder involvement is very

latelate

AJR 2005; 184:143-150

Renal Parenchyma Renal Parenchyma MalakoplakiaMalakoplakia

(RPM)(RPM) Inflammatory condition to chronic E. coli Inflammatory condition to chronic E. coli

infectioninfection Disordered macrophage response to bacterial Disordered macrophage response to bacterial

phagocytosisphagocytosis histologic hallmark is basophilic inclusions histologic hallmark is basophilic inclusions

(Michaelis-Gutmann bodies) within large (Michaelis-Gutmann bodies) within large eosinophilic macrophages (von Hansemann eosinophilic macrophages (von Hansemann histiocytes) histiocytes)

Entire GU tract can be affectedEntire GU tract can be affected Most commonly urothelial plaques (bladder esp.)Most commonly urothelial plaques (bladder esp.) RPM occurs uncommonlyRPM occurs uncommonly

Usually middle age women with h/o chronic Usually middle age women with h/o chronic infectioninfection Flank pain, feverFlank pain, fever

Renal Parenchyma Renal Parenchyma MalakoplakiaMalakoplakia

(RPM)(RPM) Findings:Findings:

Bilateralor Bilateralor unilateralunilateral

Focal, multifocal Focal, multifocal or diffuseor diffuse

infiltrating infiltrating massesmasses

Renal pelvis Renal pelvis involvement may involvement may occuroccur

Calcifications Calcifications uncommonuncommon

Radiographics. 2000;20:215-243.)

Fungal DiseaseFungal Disease Usually Usually

immunocompromised immunocompromised (DM, steroids, HIV, etc.)(DM, steroids, HIV, etc.)

Candida most commonCandida most common Any portion of urinary Any portion of urinary

tracttract ImagingImaging

Changes of PN, abscessChanges of PN, abscess Fungus ball in collecting Fungus ball in collecting

systemsystem Non-stone (echogenic) Non-stone (echogenic)

filling defectfilling defect DDX: sloughed papilla, DDX: sloughed papilla,

tcc, clottcc, clot

OutlineOutline

PyelonephritisPyelonephritis Renal AbscessRenal Abscess Emphasematous PyelonephritisEmphasematous Pyelonephritis PyonephrosisPyonephrosis Xanthogranulomatous PyelonephritisXanthogranulomatous Pyelonephritis TBTB Renal MalakoplakiaRenal Malakoplakia Other InfectionOther Infection

renal inflammatory disease

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